Click here for Press Release of AIPSN5JulyStatementonVaccinesandDrugs

AIPSN Statement on Covid-19 Vaccines and Treatment Drugs

India must follow Transparent, Reliable, Scientific Clinical Trials Protocols

Development of vaccines and medicines that treat Covid-19 are extremely important elements in the ways to overcome the Covid-19 pandemic. Around 150 vaccine candidates are currently undergoing pre-clinical and clinical trials globally, though none are yet available. However urgent the need, this vaccine development must also ensure both efficacy and safety, otherwise it will endanger the efforts to overcome Covid-19 and also vaccine programmes against other infectious diseases.

Scientists working in the National Institute of Virology (NIV) under the ICMR and Hyderabad-based BBIL have developed an inactivated vaccine candidate, BBV152 COVID, using a virus strain isolated in NIV. BBIL got approval for Phase 1 and Phase 2 trials on June 29 from the Central Drugs and Standards Control Organisation (CDSCO) as part of the fast-tracking of the process even while pre-clinical animal trials are still underway. According to the submission of BBIL with the Clinical Trials Registry of India (CTRI) also under ICMR, the enrolment for Phase 1 was to begin from July 13th and the duration of the trial covering all the three stages was to be 15 months. 12 hospitals with widely varying track-record and experience in vaccine trials have been selected for the purpose by ICMR in an entirely arbitrary and non-transparent manner.

On July 2nd, Dr. Balram Bhargava, Director General, ICMR, who is also Secretary, Health Research in the government, sent a letter to BBIL with copies to the 12 chosen hospitals for the trials saying that “it is envisaged to launch the vaccine for public health use latest by August 15th, 2020,” that is in less than 6 weeks compared to the planned 15 months.  The letter demands that subject enrolment be initiated no later than 7th July 2020, even though the CTRI registration itself shows July 13th as enrolment initiation, leaving no time for proper consideration and approval by the respective institutional ethics committees. Finally, the letter threatens these hospitals that “non-compliance will be viewed very seriously,” adding that the vaccine project is “being monitored at the top most level of the Government.”

Since “top most level of government” has been invoked, DG ICMR’s deadline appears for enabling the Prime Minister to announce “successful development of a Covid vaccine by India, before any other country,” from the ramparts of the Red Fort on Independence Day. However, as India’s premier scientific and medical research body, ICMR knows well the rigorous protocols required to be followed for vaccine trials, and therefore also that a deadline of 6 weeks to complete all three phases is scientifically absurd downright dangerous, and will cause serious damage to the reputation of Indian science and research. A desire to grandstand and please the political masters seems to have overtaken science and ethics within ICMR.  AIPSN deplores the emerging trend in India of short-circuiting established protocols for trials of Covid19 vaccines and treatment drugs.

Earlier, there was the instance of Coronil, an ayurvedic mix sought to be launched for treatment of Covid-19 by the Patanjali group headed by Baba Ramdev, based on spurious, improperly conducted and assessed clinical trials. . After uproar by scientists and in the media, the AYUSH ministry prohibited Patanjali from selling or advertising Coronil as a treatment for Covid-19. However, nothing was done about Patanjali not following due process of clinical trials and approvals. Glenmark obtained approval from DCGI for Covid19 treatment without any trials in India for manufacture of the antiviral drug Favipiravir. At a cost of Rs 103 a tablet and needing 122 tablets for a full course, the company stands to make a killing in profits. Highlighting the dangers of such hasty approvals without due process, the Lok Nayak Hospital in Delhi recently decided to stop using Favipiravir for Covid19 treatment following observations of problems in heart rate and uric acid levels in patients.

ICMR has also persisted with guidelines to administer Hydroxychloroquine (HCQ) to frontline health care workers and care-givers for patients in home isolation as a prophylactic. It is supposedly a ‘trial’ but without the strict protocols required for a trial. This despite published results of international trials showing lack of efficacy and possible adverse side-effects, and WHO guidelines against use of HCQ.

AIPSN demands that the due process of scientific trials be followed strictly and transparently for all Covid19 candidate vaccines and treatment drugs, regardless of systems of medicine, and overcoming temptations to make haste prompted either by corporate greed or false national pride.

AIPSN calls for a globally coordinated effort that puts people before profits to make drugs and vaccines that will be available free to the public and with allocations to countries made as per needs without any discrimination instead of the current perverted race to develop drugs and vaccines driven by jingoistic-nationalism and corporate profits.

AIPSN demands that the efforts of the scientists who came up with the BBV152 COVID vaccine candidate, or others likely to come up in the near future, not be wasted by such unseemly political pressures which compromise the safety of people by not following due process and which is highly likely to bring Indian science and research into disrepute.

For clarifications contact:

P. Rajamanickam  9442915101    D. Raghunandan  9810098621

click here for SummaryofPost-May3-LockdownStatement

click here for English version JSA AIPSN statement_Post-May3_Lockdown 

click here for Bengali versionBengali-JSA-AIPSNstatementonPost3rdMay-measures

Statement on post-3^rd May 2020 measures against Covid-19 Pandemic

 Jan SwasthyaAbhiyan (JSA) and All India People’s Science Network (AIPSN)

Background

 The Central Government has persisted with the Lockdown as the main, if not, the only strategy against the spread of COVID-19.  Underway since March 25^th, this lock-down has seen two extensions, one on April 20^th and now again on May 3^rd.  These one-size-fits-all country-wide lock-downs are badly planned and poorly implemented with measures imposed on the country by the Government using centralizing powers under the Disaster Management Act.

More than 28 Joint Statements released till nowby Jan SwasthyaAbhiyan and All India Peoples Science Network (JSA-AIPSN) have been released. These statements explain in detail why such all-encompassing restrictions of movements and activities that India has executed is a fundamentally mistaken approach with limited and temporary benefits, that fails to factor in Indian socio-economic realities. This will lead to many long-term adverse consequences.

WHO, public health experts and best practices of many countries all agree that population lockdowns are at best temporary, locale-specific, emergency measures which need to be accompanied by other more important health-related and socio-economic measures which we list as follows:

• extensive and rigorous contact tracing, wide-ranging and purposive testing, quarantining and isolation as required, and hospital treatment of infected persons
• buildingup preparedness of health systems using the lockdown leeway to respond to the anticipated high case load arising from Covid-19
• ensuring that the health system caters simultaneouslytonon-Covidhealth needs especially relating to maternal and child health, chronic or life-threatening ailments and needs of the elderly, disabled and other vulnerable sections
• ensuringreliable supply of and access to essential goods and services, especially to meet needs of the poor, elderly, disabled and other vulnerable sections
• financial and other special provisions for those who would lose essential incomes and jobs, such as migrant workers, daily-wage earners, the self-employed and workers in the unorganized and SME sector
• humane, effective and non-stigmatizing approach towards infected and suspected cases, and the economically worst-affected populations, with participation of community volunteers and civil society organizations as appropriate
• effective coordination between Centre and States/UTs, as the latter is being starved off revenues while also coping with demands arising from the Covid-19 epidemic.

However,although the lockdown is being implemented vigorously, none of these parallel measures have been implemented in the required scale and intensity. As a result, the capacity to undertake public health and economic measures to cope with the inevitable increase of infections when the lock down is lifted, are still not in place. The lockdown itself has also been imposed and implemented in a non-transparent manner without the epidemiological evidence required to inform both the classification of areas and the choice of activities to be restricted.

Current Status: The Central Government and its departments/agencies including the Ministry of Health and ICMR have been making various often unsubstantiated claims about the success of the lockdown,such asthat many more cases would have occurred without it, that the rate of new cases is becoming linear, that no community transmission is taking place, and so on. The reality is thatcases are fast rising especially in certain States/Districts, with surprisingly high fatality rates in some. There is substantial uncertainty about the true extent of spread given low testing rates, among the lowest in the world at around 0.4 tests per thousand population compared to the global median of 5.9 tests per thousand. Further, symptomatic cases without contacts have been largely excluded from testing by protocol.  Infection is certainly spreading to new areas through what is euphemistically termed “large outbreaks of local transmission” by the government. There are significant numbers of cases without any connection to persons with travel or known contact history.The rates of increase remain significant and accelerating. Whereas it took 10 days to go from 5000 to 15,000 cases it took only 5 to 6 days to go from 25,000 to 35,000 cases.

However, these all-India numbers mask the stark reality that the case load varies widely between States and also within States.At the time of writing the statement, 5 of the total 36 States/UTs have zero cases,130districts have been classified as “red zones”, 284districts as non-hotspot “orange zones”and319districts in 25 States reporting no new cases in the past 21 days as “green zones”. This colour-coding of districts and containment zones is not based on clear, stable and transparent epidemiological criteria, and yet forms the basis for policy recommendations for containment measures.

On top of this, within the red zones even more intensive “containment zones” or hotspots have been identified based on even weaker and more opaque evidence, but where even stricter forms of lockdowns have been imposed.

In light of this situation, the following steps are urged in the coming period:

1. Strengthen the disease surveillance mechanism, inclusive of COVID 19 surveillance,with appropriate design for collection, flow and analysis of information so that it can inform decision making for epidemic control at national, state and local levels as well as provide information on collateral costs in lives lost and morbidities due non-COVID causes.
2. Zero case reporting should not be made the exit criteria for lock-downs or basis for any zoning. Such unnecessary and unrealistic criteria run the danger of systems suppressing data to report zero cases. The realistic objective is to achievea manageable number of infections or case increase rates at any point so as not to overwhelm the system and to reduce deaths by protecting those that are particularly vulnerable to severe disease.
3. Many restrictions have no rationale in public health such as the country-wide restriction of movement after 7 pm. The specific rationale for such measures should be explicitly stated and subject to audit and review by impartial watchdog bodies.
4. Adopt a framework of participatory governance for determination of criteria for restriction of movements and activities, and guidelines for implementation of relief measures and allocation of resources. This could subsequently become part of a legal framework that would mandate functional consultative mechanisms involving public health expertise, health care providers and civil society organizations including of working people, all of whom would be affected. Such legislated provisions would also mandate watchdog bodies to ensure that the sweeping powers given under the Disaster Management Act are used in consultation with affected people and groups, and that the participatory framework is maintained.

Restrictionson Movements and Activities: It is strongly urged that a calibrated and graded easing of restrictions on movement and social and economic activities takes place, with broad guidelines within which States may decide on the extent of these restrictions.The main principle for making and implementing restrictions is that this must not call for creating or strengthening police raj using Sec 144 and other coercive measures. The public should be treated in a humane manner and as partners in the process, and not as criminals or subjects under colonial rule.

Relaxations should aim at reviving economic activity, especially in the unorganized and small-scale sector  while continuing to practice physical distancing and other precautions, improving services required by common people especially the elderly and vulnerable sections , considerably strengthening the health system to handle both Covid-19 and pressing non-Covid issues, and stepping up efforts at containment through expanded and rigorous testing, tracing, isolation or quarantining, and treatment. We note that several restrictions such as on agriculture, agricultural markets, fisheries, forest produce etc., as well as on enterprises in rural areas and activities by plumbers, electricians and carpenters in urban areas, have already been relaxed.

The following (indicative not exhaustive) additional relaxations beyond those already permitted since 15 April are urged, with States to decide on fewer relaxations in “red zones” if felt necessary:

1. Inter-State and inter-district movement of all goods should be freely permitted in view of the current severe shortages and supply-chain constraints impacting even food, medicines and other essential goods, besides other manufactured goods;
2. Students, tourists, and families that are separated and others who have been stranded by the lockdown should be allowed to book tickets in suitable public transport arrangements including special buses, trains and flights which are organized for this purpose, and facilitated to reach their destination within the next few weeks. Migrant workers should be transported to their native villages free of cost, so as not to add to their enormous burden they have already had to take on due to the lockdown.Those with symptoms suggestive of COVID 19 should be checked before travel and retained pending observation and subsequent clearance. . Further restrictions on public transport must be eased based on evidence

• All small-scale manufacturing and service enterprises be permitted to function in urban areas with suitable guidance on work-from-home where possible, proportion of personnel attending per shift, use of own or company transport, physical distancing and provision of protective measures such as washing stands, sanitizers, masks etc

1. All home-based enterprises, self-employed occupations and services such as care services, air-conditioner servicing/repairs, water purification and provisioning, neighbourhoodlaundries and pressing, courier services, roadside vegetable/fruit vendors, florists, and other similar categories should be permitted. Only exceptions can be stated such as where services providers are numerous with crowded clientele making social distancing difficult
2. Skeletal public transport and a limited number of taxiservices should be made availableand personal vehicles be permittedfor essential purposes like access to healthcare and for the vulnerable. Many of these should be decided locally and not micro-managed from the central MHA.
3. Types of shops allowed to function from local markets may be expanded to include hardware stores, electrical supplies, sanitary ware stores, cell phone repair, bakeries, hosiery and undergarments, stationeryetc., and small restaurants for home delivery.
4. Based on data related to social mixing and disaggregated infection rates, several countries have worked out risk criteria for different types of services according to which certain services like cinema halls, malls and pubs are kept closed for the time being while some other services such as restaurants operating at 50 percent of less occupancy with physical distancing norms are allowed to open.; some countries have opened up primary schools, others have allowed public transport and so on. Similar risk-criteria may be evolved for India and services opened up accordingly

 The efficacy and effectiveness of the “containment areas” approach is questionable on epidemiological and other grounds and measures implemented within these areas are highly arbitrary and unrealistic. If essential needs like outpatient healthcare or food purchases are disallowed, then people are forced to breach the containment perimeter by subterfuge to meet these needs. Further, once these areas are opened up, they are as vulnerable as before to infection from nearby areas. Whereas neighborhood spread is not a feature of the epidemic, such forms of containment may actively lead to it. This is essentially a policing approach that cannot be a substitute to contact tracing by community health workers with active community participation.

 Hospitals and health care: Focus of the government hitherto has been almost exclusively on preparing public hospitals dedicated to Covid-19 care, to the extent that other important health services have been sidelined causing enormous problems to persons suffering from various chronic or life-threatening ailments and increasingly even to maternal and child health. Earlier JSA-AIPSN Statements have elaborated on this issue in considerable detail. Government claims that sufficient beds are now available for handling Covid-19 patients, but ground realities are that hospital beds have mostly been diverted from other non-Covid requirements, and ICU Units properly equipped with oxygen and ventilators are in extremely short supply even in metropolitan cities, for instance in Mumbai. OPD and many other services in public hospitals have also been suspended with, for example, outstation patients and their caregivers stranded in makeshift shelters in Delhi for over a month waiting for cancer or other treatment.

It is also notable that medical professionals and other health workers and auxiliary personnel have become infected by Sars-Cov-2 in sizeable numbers and hospitals have themselves become major “hotspots” for infection spread for a variety of reasons, most of which were avoidable.

1. In light of this situation, the following steps are urged in the coming period:
2. Urgently expand the number of beds and well-equipped facilities for isolation and initial treatment of Covid-19 patientsthrough non-hospital re-purposed facilities such as sports stadia, conference halls, panchayatbhavansetc, including by erecting purpose-built field facilities, so as to reduce pressure on hospitals . Where the patient is COVID 19 positive, institutional isolation with suitable medical care must the only option. Home isolation can only be considered in exceptional circumstances.
3. Better equip dedicated Covid-19 hospital facilities for management of severe disease.
4. Stop the conversion of functional multi-speciality public hospitals currently working on full capacity, leading to denial of access to essential healthcare for close to half the population in many medical disciplines. Where there are no other under-utilized public or private hospitals that can be re-purposed, with segregation of one wing of the public hospital and entrance through a separate gate, while ensuring all other departments function in same volumes as before could be a temporary arrangement. But in parallel- the government must rapidly build up new public hospitals.
5. Conduct independent audit of hospital procedures and protocols to prevent hospital acquired infection using standard quality accreditation guidelines as well as COVID specific guidelines in all hospital, public or private, irrespective of whether they are seeing COVID 19 patients.
6. Rigorously identify and test all symptomatic patients for Covid-19 infection, as also all patients with co-morbidities that are known for association with COVID 19 infection.
7. Provide appropriate PPE for all health care and auxiliary personnel in hospitals handling both COVID and non COVID patients.
8. Extend training, PPE and other support measures commensurate with requirements to ASHA workers and other community health workers, sanitation workers, police personnel, administrative staff, social workers, and volunteers working in potentially high-infection environment.
9. Ensure continuity in care, including access to diagnostics and medication and out-patient and in-patient care for serious. chronic and life-threatening ailments
10. Ensure safety of doctors and other health-care workers through provisioning of PPE in requisite quantities and quality standards
11. Ensureadequate ambulances and/or other vehicles for speedily bringing patients requiring hospitalization for both Covid-19 and non-Covid19 cases
12. Induct volunteers of recovered Covid-19 patients for interfacing between the public and the health care workers with periodic testing as required to ensure there is no recurrence.
13. Provide mental healthcare services as required to health workers, Covid-19 patients and their families, and to address mental health issues among school children, adolescents and others arising out of lockdown.
14. Strongly come down on the touting of fake cures and remedies, “immuno-boosters” and other similar gimmicks, including their advertisement on television and other media

 Quarantine: Contact tracing and quarantine of asymptomatic contacts of Covid- 19 is an essential component of epidemic control. However in densely populated slum and low-income areas in cities, there is little scope for home quarantine due to over-crowding, poor health systems support and lack of trust between authorities and residents. Recent instances of persons being kept in large numbers in a single room in Delhi with a common, dirty toilet, or of poor people being kept in UP like caged animals with food being thrown at them, show the utter callousness and carelessness with which quarantine is being viewed, except for the well-off who may stay in their own homes or even in hotels on payment.

In light of this situation, the following steps are urged in the coming period:

1. Institutional facilities for hygienic, effective, dignified and humane quarantine must be sharply increased for all classes and categories of persons, with adequate provision of nutritious food and other essentials.
2. Clear standard norms of institutional quarantine that includes medical and public health features as well as considerations of comfort, convenience, privacy and human dignity should be urgently drawn up, disseminated and rigorously monitored, including through community based people friendly mechanisms.
3. Such facilities may be created in repurposed public buildings, schools, college and university campuses, and other requisitioned private/institutional buildings or purpose-build facilities as required.
4. As many of these facilities as possible should be community managed, often engaging recovered patients from that very community in the management, so that there is trust and humanity in the way this is dealt with. Assistance of civil society organizations may be promoted and utilized in a coordinated manner.
5. In situation where it is reasonable to accept compliance and there is good community support and linkages with the health system, home quarantine can be permitted.

Testing and Tracing: The recommended relaxation of restrictions should be accompanied by expanded and more rigorous tracing and testing of all suspected cases, so that quarantine of contacts, and isolation and treatment of the infected are vigorously pursued towards breaking the chain of infection.In so-called red zones suspected cases,based on clinical symptoms and contacts of known positive cases need to be pro-actively identified through door-to-door surveillance contact-tracing and contact tracing.  Yet despite all the time gained by lock-downs the access to testing remains far below what is required for both individual patient management and for epidemic control.

In light of this situation, the following measures are urgently required:

1. Testing protocols currently specified by ICMR need to be revised to permit testing of all persons with symptoms suggestive of Covid-19 infection (mild, moderate or severe) as well as asymptomatic contacts. It could be further scaled up to include asymptomatic people without contact history if infection is high enough to label it a “containment” hotspot. Some of those at high risk like health workers in the COVID frontline may require periodic testing, while others may require testing if they develop symptoms.
2. Access to both viral antigen testing and rapid antibody testing needs to expand. Rapid antibody testingis very useful tool that clinicians can use to rapidly confirm diagnosis within a clinical setting, and for sero-surveillance including in so-called “green zones” for understanding spread of infection and the development of herd–immunity. In many clinical settings viral antigen tests would be required even if it is more difficult to access.

Test kits & PPEs:Test kits and PPEs need to be procured expeditiously in sufficient quantities and distributed to States proportionate to requirement. While government spokespersons have repeatedly released figures of Test Kits and PPE ordered, which was done very belatedly as recent revelations show, delivery has actually been slow. Official statements indicate that the required larger numbers of PPEs and test kits may not be available before end of May or even June, which is totally unacceptable. Poor procurement policies, delayed validation and an over-reliance on one or two foreign suppliers have led to this crisis. Indigenous PPE manufacture has been slow to pick up partly due to lock down related barriers of access to raw materials and labour. Indigenous test kit manufacture has also faced problems of delayed validation and is taking time to scale up to required levels.

In light of this situation, the following steps are urgently required:

1. Bottlenecks in manufacturing clearances and domestic production need to be urgently addressed, especially as regards supply chains and transportation.
2. Financial support should be extended to domestic manufacturers in order to scale-up and speed-up production, with products of adequate standards commensurate with international norms; this should be done with a long-term perspective of building up indigenous capability and eco-system in aspects of the value-chain towards a globally competitive medical equipment industry in India.
3. Validation and other clearances should be accelerated for indigenous tests developed (as for example the Chitra Tirunal RT-LAMP test or the CSIR-IGIB test kit) in order to include them into the program and expand the options available.

Stigmatization:The entire approach of the Government as well as its explicit messaging have been founded on creating fear which in turn has been transformed into stigmatization and aversion by a petrified public. Despite all the government-organized clapping and lamp-lighting, doctors, nurses, sanitation workers, testing technicians and even airline pilot and crew have been targets of stigmatization among all classes. Even the dead have not escaped this stigma. Stickers, posters, wall paintings etc. outside the door of quarantined persons have only increased the perception of infected persons as “the enemy,” to be shunned or even fought off. Various tracking apps will only make this worse and add to the surveillance capacity of the government well beyond this epidemic. Without trust and public cooperation they are unlikely to be effective. These tracking apps have therefore been opposed by many civil society organizations, especially those specializing in internet and data privacy.

The communalization of the epidemic, which has itself acquired epidemic proportions, is an extreme form of this stigmatization and needs to be fought back by all concerned, especially by the Government.

In light of this situation, the following immediate actions by the government are required:

1. Government must actively lead health education (IEC) activities that de-stigmatize the disease and promote a better understanding of how it spreads. Its message should be reviewed to ensure the messaging does promote social solidarity, not fear, guilt or hostility.
2. All norms of privacy and confidentiality of individuals and communities must be respected. A serious campaign must be organized to de-communalize the disease
3. Government must stop targeting its political dissent and making arrests and restrictions on political grounds using the opportunities provided under the draconian disaster management act and the difficulties in access to court. This is essential for building a broad based trust.

Gender based violence: The lockdown period has aggravated situations of violence that happen to people on the basis of their gender, sex, or sexual orientation-women, girls, trans-persons, children and others. Being restricted within homes/families has meant for many women and others to be isolated with their abusers. It has not only meant being more exposed to ongoing violence but also the inability to move out seeking protection and care. The sudden enforcement of lockdown and subsequent suspension of transport facilities/mobility has predictably led to this scenario as it created barriers for those who would have wanted to move out of situations of violence in the given context. Even before Covid-19 situation, gender based violence has existed as a pervasive issue having enormous impact on lives of survivors including negative health outcomes, thus forming a crisis situation of its own which was completely overlooked given the way lockdown was enforced with least sensitivity to the needs of these survivors. Overlooking one crisis while gearing upto respond to another- is paradoxical at least; and violation of the rights of survivors at large.

There are also,very disturbing instances of violence against women in quarantine facilities and at hospitals being reported must be urgently looked into and dealt with to ensure that no such violations happen in future. At a crucial time when the hospitals, healthcare workers and systems are seeking support of the communities and its varied members for their voluntary cooperation to control the spread of Covid-19, such incidents unfortunately breaches the trust of the communities, particularly women for trusting their well-being with the government systems.

Given this situation, we call on the government to take the following steps:

1. Prevention and redress of gender based violence must be made an important aspect of national response plans for Covid-19. The governments must send a clear message against all forms of gender based violence including sexual violence in all spheres of lives including health facilities and quarantine spaces. Public health preparedness, systems and protocols in the current context must take additional measures towards ensuring a dignified healthcare for all women, girls, and other marginalized groups.
2. Special emergency fund should be declared and allocated for responding to gender based violence in the current context including the utilization of existing Nirbhaya funds with states- with requisite directives and flexibility to draw up response suitable to different contexts.
3. Essential service providers must be recognized at the administrative level-including government helplines, one stop centres, police, protection officers, medical officers, legal services authorities, counsellors, shelter homes etc. and ensure that they remain operational universally.
4. Government should call for urgent consultation with women’s groups/organisations working on this issue to ensure a concerted/organized effort during the Covid-19 situation.

 Migrant Workers: Last but not least, is the terrible situation that migrant workers find themselves in, which is a massive blot on the governance system and the reputation of our country. These workers are the backbone of the Indian economy.They earn their livelihoods however meager with dignity, and do not deserve to be treated as supplicants. This crisis must be resolved urgently and humanely.We note that after a long and inexplicable delay, permission has been given to run special trains for migrants to return, but even this move is as yet inadequate in scale and support systems. Moreover, it has been reported that the workers are being made to pay for their travel back, which is completely unethical. Many migrant workers have already been subject to brutal and hostile quarantine conditions and many are exhausted by hunger, disease, heat and the exertion of trying to walk back home.

In such a context, we call on government to take the following measures:

1. Arrange adequate number of special trains for returning migrants to their home states, and further buses within the states for them to reach their home village. These should be provided completely free of cost.
2. Ensure that those who have symptoms are tested, and allowed to board only if negative. If positive they must be hospitalized at state expense, and when they become negative catch the next train back. Those who have no symptoms can be allowed to return without any further tests.
3. Arrangements for proper quarantine according to specifications as discussed above should also be made in their native villages or districts, if they are coming from a higher infection zone to a lower infection zone.
4. Transportation conditions should be decent with food and clean toilets ensuring physical distancing.
5. Whatever meager support migrant workers have been extended by the Centre and by some of the States where they had come to work and live, has been too little and too late. They require to be compensated for loss of income incurred due to the lockdown, and provided with financial assistance through MGNREGA or other means after they return to their villages.

Relief Measures for all Working People: The government has announced a slew of relief measures. JSA-AIPSN in an earlier statement has pointed out to the inadequacy of many of these measures, both in terms of covering all those who require relief and on the scale of relief provided.

As the government goes into the second extension of the lock-down we note that most of these relief measures are yet to reach the majority for whom it is intended. No further measures from the government have been forthcoming. Only very few states have been able to supplement this package of relief. There are also many categories of workers like non-migrant urban poor staying in the slums, are out of work, and have no access to social security measured and food security entitlements and have no relief package directed at them. A number of NGOs are valiantly try to close the gap with community kitchens,- but the scale of this effort is too small.

In this context we call upon the government to:

1. First and foremost implement the promises it has made with respect to relief and ensure that bureaucratic barriers and implementation failures do not exclude large sections of those who need relief or fail to deliver the necessary quantity of relief.
2. Announce an increase in the resource allocation and use this to expand the scope of relief measures that are provided to the working people, especially the most vulnerable sections who are bearing the brunt of this crisis. The longer such lockdown continues the higher would be such burden on them.
3. Expand food supplementation and food security arrangements as called for by the Right To Food Campaign, without any mandatory requirement of Aadhaar. The FCI currently has a stock of over 60 million tonnes of grain, which should be distributed among the population.
4. Expand the MGNREGS to reach a much wider section of rural workers and extend it to all urban workers, so that all those in need of employment are able to secure employment for at least 200 days in the coming year, wherever they are resident. The kind of works permitted under MGNREGA should also be expanded and a basic unemployment allowance would be required in many states.

For more information please contact:

D.Raghunandan – 9810098621

T. Sundararaman – 9987438253

N. Sarojini  – 9818664634

Sulakshana Nandi – 9406090595

Follow for regular updates:

Website          www.phmindia.org               www.aipsn.net

Twitter           @jsa_india

Facebook       @janswasthyaabhiyan

Summary-health-worker-rights-Position-Paper

Position-Paper-Health-Worker-Rights_Final

POSITION PAPER
Health workers’ rights in the time of COVID-19
by Jan Swasthya Abhiyan (JSA), All India People’s Science Network (AIPSN) and
Public Services International India National Coordination Committee (PSI India NCC)

21 April 2020

Introduction
As of 21 April, the COVID-19 pandemic has infected about 2,482,158 people worldwide and contributed to 170,470 deaths. In India as on 20 April, the number of people infected with COVID-
19 is 17,656 with 559 deaths. The corona virus Sars-CoV-2 that causes COVID-19 is potent for certain biological reasons―its structure enables it to latch on to hosts easily, it has a long infection period, it is infectious even in asymptomatic carriers, and human beings have no immunity to it as yet. Hence it can spread easily and quickly. A large, sudden influx of patients can put extreme stress on both the healthcare system in India and on its health workers, as we are currently witnessing in many countries in Europe and the United States. Health workers are generally at high risk. In Italy for instance, it has been reported a staggeringly high proportion of all those infected are healthcare workers. India is witnessing an increasing number of cases of infection among health workers.
The situation is made worse by the fact that COVID-19 has hit India against the backdrop of a neoliberal assault on healthcare. This assault has meant that public health facilities are in disrepair,
neglected, and overburdened. At the same time, private hospitals and nursing homes have proliferated, without adequate regulation.
The main rationale for the poorly planned 27-day lockdown and its extension upto 3 May by many states, with disastrous effects on lakhs of informal and migrant workers, is that it will buy time for the government to prepare for COVID-19’s likely assault. However, governments’ actions
till now have been both late and inadequate. The current situation is dire. Testing is inadequate, there is severe scarcity of test kits and the much-publicized antibody-based kits have barely begun trickling in, more ventilators are needed, and the availability of personal protective equipment (PPE) is poor and uneven across regions and hospitals. Moreover, the high population density in slum settlements and bastis in all towns of India makes physical distancing, even in a period of lockdown, impossible and puts the poor and a very large number of workers at risk of infection.
Additionally, health facilities can become sources of the spread of infection, with three concentric circles of risk: individual health workers in direct contact with patients; other employees including fellow-nurses, doctors, and other health workers; and three, the public coming to a hospital.
Recent episodes, such as in Delhi, Mumbai, and Hyderabad have shown that this can occur at any health facility, not just at COVID-19-identified ones, particularly given that the current Indian testing and patient management protocol has no provision for testing symptomatic patients without a contact history and isolating those who are positive but asymptomatic. These patients might have high infectivity and will be coming into close contact with many healthcare providers without either patient or health providers knowing. There are also asymptomatic carriers in the public, many of whom will be seeking care due to co-morbidities. Health workers at the community level, such as ASHAs, who are deployed either for Covid-19 outreach and community awareness or for routine community level work such as immunisation, are also facing higher risk of exposure to the virus.

Hence, the rights and protection against risk of health workers on the one hand, and the robustness of the health system on the other, and the policies with regard to testing, all deeply intersect in the
times of COVID-19.

Because health workers are on the frontlines of our response to COVID-19, they face higher risks of infection, overwork, and stress. Hence, any strategy to fight the pandemic should consider the rights and protection of health workers, including through the following:
(a) adequate PPE should be provided;
(b) access to testing and treatment needs to be ensured;
(c) health workers should be covered for COVID-19-related sick leave, quarantine and provided compensation;
(d) workers should be allowed to opt out of performing their work in conditions that puts them at risk, without risk of losing their jobs;
(e) proper training needs to be provided regarding procedures before workers are deployed;
(f) representatives of health workers need to be actively involved in setting up safeguard measures in health facilities;
(g) the organization of work in hospitals (such as patient flow in the outpatient wards) should be such that their risk of exposure to healthcare workers is minimized;
(h) wages and overtime should be paid as per the law without any mandatory or so-called voluntary cuts;
(i) adequate facilities should be provided across needs such as adequate accommodation, transportation, child care, and nutritious meals;
(j) measures are urgently required to protect health workers against stigma, violence, discrimination, and sexual harassment;
(k) existing vacancies need to be filled with a long-term perspective;

The COVID-19 crisis and the effectiveness of health systems response both in India and globally, clearly underlines the need for healthcare to be in the public sector. The related, broader issues of health workers’ employment, equal pay for equal work, and rights to occupational health and safety and better working conditions is central for countries to be able to cope with COVID-19 now. We welcome the broader support and appreciation for the work that health workers are doing in the forefront in the fight against COVID-19. However, just appreciation and statements of good
intent are not enough. Nor are simply clapping hands and banging plates. We need this support to be legalized through notifications and legislation by the appropriate authority at varied levels of government: centre, state, and local bodies. How robust we make the healthcare system and strengthen
all health workers now is central to coping better not just with the present crisis, but how well we will be able to cope with any health crises in the future.

A precarious health workforce makes the health system more fragile.
The continuous underfunding of public healthcare has meant that in public hospitals, due to budgetary tightening, vacancies of health professionals―from doctors, to nurses to paramedics―have not been filled. This imposes a heavy workload on the existing staff that was
already hard for them to manage. In many facilities, especially under local bodies and poorer state governments, professional staff shortages have been dealt with by hiring on short-term contracts or deploying field staff in hospital settings, such as with ANMs. Health workers who are ‘non-profes-
sionals’, such as ward attendants and housekeeping staff, cleaning and security staff are most often hired through contractors, at low wages, pathetic working conditions, and too often in violation of the labour law.
While the private health sector has thrived and expanded, its workforce is highly underpaid, except for high profile and specialised doctors. Across the country, nurses in private hospitals are, at best, paid around the minimum wage for a skilled worker, and most often below this legal benchmark. This sets the scale for other staff, who also face the challenge of being hired through a third
party which makes their tenure highly insecure and without social security coverage.
The workforce at the primary level of care provided in health posts and at the community level are unarguably the most neglected. Field/community health workers, such as the Accredited Social Health Activists (ASHAs) in rural settings or Community Health Volunteers (CHVs) in Mumbai, are the largest group of health workers with more than 9 lakh workers in India. They are denied the status of a worker by the State. ASHAs are told they are ‘volunteer’ activists and not workers of the health system, thus denied minimum wage and any other rights of a worker under the law.
As health workers across the health system have been mobilised to respond to the pandemic, the pre-existing cracks and weaknesses in the system make it all the more fragile. Informal employ-
ment leads to unclear responsibilities towards workers, and has created blind spots in the system.
ASHAs and CHVs have been deployed for case identification without adequate safeguards. Sanitation and support staff who are contractual are being preferentially deployed as compared to regular staff, so as to avoid social security obligations in case of their illness. Public hospitals will be at the
centre of the response to the COVID-19 epidemic, but they will have to be reinforced by private facilities, either through collaboration, or preferably, through requisition by the government. The precariousness faced by the vast majority of the close to 40 lakh health workers has to be addressed as a matter of priority as part of health system preparedness that the lockdown is meant to enable.
Previous outbreaks of highly infectious communicable diseases have demonstrated that public health outcomes are significantly improved when labour rights are respected, and trade unions are able to effectively represent workers actually exposed and potentially exposed to the disease.
The active involvement of health workers’ representatives in government decision-making is necessary to safeguard workplace safety and health and ensure the cost of the crisis is not borne by healthcare personnel.
REQUIRED MEASURES
a) Adequate provisioning of Personal Protective Equipment
Reports coming in from Maharashtra, West Bengal, Tamil Nadu, and Bihar point to uneven availability of PPE of adequate quality, leading to protests. Workers are worried that raincoats are provided instead of medical gowns, that eye protection and other equipment has not been provided. Workers are forced to do risky procedures without proper PPE, or asked to quit if they refuse. This is creating confusion on stress amongst the health workforce and needs to be urgently addressed.
The guidelines of the government of India – that make recommendations regarding the use of specific PPE for different categories of workers, including medical masks, gloves, gowns, eye protection, and footwear and respirators depending on the kinds of patient care – have not been adhered to.
Even the WHO interim guidance of 19 March 2020 on Rational Use of PPE for coronavirus disease (COVID-19) have not been followed. Newguidelines (dated 20 April) acknowledge the risk of infection by asymptomatic patients who visit a health facility for other health reasons, yet they do not provide guidance on PPE requirements. We recommend that the Indian government ensures systems to monitor and enforce strict adherence to adequate guidelines for the use of PPE.
There has been a clear and criminal lack of preparedness and stockpiling, in disregard of WHO guidelines of 27 February 2020. The Ministry of Health has admitted a shortage of equipment and supply not meeting rising demand. This is compounded by an inadequate estimate of the size of the health workforce, which the government estimates at 22 lakh, while it should be closer to 40 lakh (A 2016 estimate suggests that the number of health professionals and para professionals alone (including doctors,
nurses and midwives, dentists, laboratory technicians and paramedics) was close to 25.3 lakh. The latter does not
include health workers such as cleaning staff, ward attendants, ambulance drivers, ASHAs and ANMs, to name a few. ASHAs alone are estimated to around 8.5 lakh, ANMs to around 2 lakh. While there is no estimate available for
ancillary health staff, it is safe to presume that at least 2 to 4 lakh, bringing the total number close to 40 lakh/4 million.)

Given the uneven nature of PPE availability across regions, we recommended that PPE be sourced
in priority from domestic manufacturers with a long-term view of development of domestic industrial capability, and supplied to deal with clusters of cases as they occur. This implies that PPE pro-
curement orders have to be increased to ensure adequate access to all health workers, and PPE be sent to regions where they are most needed.
The shortage of necessary PPE equipment and the traditional structures of social discrimination in India could lead to certain categories of workers, such as nurses who are at highest risk, but also ASHAs, non-permanent/contract workers and cleaners, not being provided adequate PPE. We urge that the government issue a directive that no such discrimination take place against any worker in any establishment. Health workers should not be forced to work under unsafe conditions without adequate protective equipment.

b) Free health care for all health workers
The announcement by the Finance Minister of a special life insurance scheme for health workers is
misleading and insufficient. Despite an announcement that all health workers would be covered, the package covers health workers in the private sector only if they are drafted for COVID-19
responsibilities. The recent case of health workers getting infected at the private facility Delhi State Cancer Institute shows that this is insufficient. Further, this is subject to the numbers indicated byMoHFW. The figure of 22 lakh health workers is a gross underestimation of the actual size of the workforce in the country, as mentioned earlier. The estimate should be modified correspondingly and increased to at least 40 lakh health workers and the omission of healthcare workers in the private sectors needs to be corrected immediately to avoid the possibility of denial of compensation.
Most importantly, this scheme is grossly insufficient as it does not provide any support to health workers and their families unless the worker dies. In case health workers are infected by COVID-19
they should be given treatment, care and support free of cost. Considering that health workers in informal employment conditions are more vulnerable as employers can hide behind this informality to deny their responsibility towards them, it is important that they are given special attention in this
regard. The latest testing protocol (31 March) has expanded testing only to symptomatic health care workers, whereas there is clear evidence of asymptomatic cases. As current testing protocols are restrictive, health workers might find that they are compelled to go for testing in private labs, and incur costs. Failure to detect infections early among healthcare workers may result in further spreading of the infection. Access to comprehensive and free health care, including outpatient, hospitalisation, and regular free testing need to be ensured, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers performing high risk tasks, even if asymptomatic.

c) Special COVID-19 related paid leave and compensation.
Health workers are at a higher risk of contracting infectious diseases, which is the case with  COVID-19 as well. Reports estimate close to 100 infections already confirmed in India, though there is no systematic reporting of this data. As facilities are short-staffed, managements of facilities are extending working hours. They might try to keep health workers on the job even when they are  already showing COVID-19-like symptoms, as we saw in Mumbai and in Bihar. Workers who have tested positive with COVID-19 should not be asked to continue with their duties if they are showing
symptoms. This is against protocols and puts the workers at more risk of developing more severe symptoms if they are not able to rest adequately.
Managements of facilities might also deduct leave taken for sickness or quarantine from existing leave provisions, and when these are used up, take recourse to cutting workers’ wages. Informal workers have a limited amount of paid leave that will run out quickly. Those on daily wages do not
even have paid leave. Special paid leave in case of COVID-19-related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third
party. A special compensation should also be announced for health workers who contract COVID-19 in line with the WHO definition that if exposure to corona virus Sars-CoV-2 happens at the
workplace, contracting COVID-19 should be considered an occupational disease.
d) Mental health support and the right to opt out
Health workers undergo considerable stress during emergencies such as the one we are facing.
Counselling and mental health support should be made available for health workers. Breaks and time-off should be maintained, as healthcare workers’ burnout could contribute to both their
catching the virus and its spread. As per WHO guidelines, health workers should not be required to return to a work situation where there is continuous or serious danger to their life or health. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected, without undue consequences.
Health workers who are pregnant, or have co-morbidities have higher chances to contract the infection and develop more severe symptoms. They should not be put on duty in the COVID-19 ward and limit exposure to patients with suspected COVID-19. Instead, they should be assigned appropriate tasks within their profession that does not expose them the virus and be accommodated if they request so.

e) Training on procedures and infection risk management
Managing the risk of infection in health facilities, both in the public and private sectors, is essential to ensure that health facilities do not themselves become hubs of infection. Part of the risk management procedure is to ensure that all health workers understand the measures that are needed to protect themselves, protect patients, and protect the facility. The government should implement or
direct facilities to implement appropriate training for the diversity of workers categories across levels of risk.
The government needs to put in place online training programmes on infection control with a focus on COVID-19 for the entire medical workforce in the country, facility-based training for the entire
workforce in each facility, including ASHA and community-based health workers attached to different health posts. All health workers should be provided with communication materials in different languages on the appropriate safeguards, including but not limited to PPEs.
The entire staff in all COVID-19 earmarked hospitals, ICU units, and isolation centres should be given training and this should include both guidelines and protocols for COVID-19 care, as well as personal safety, infection risk management and the use of personal protective equipment. The government should provide guidelines for these procedures to be followed in private facilities. A helpline should be set up for health workers who face challenges at their workplace, with a defined
procedure to register complaints and interventions to resolve them. In case private facilities fail to follow the government guidelines and resolve issues with regard to adequate safeguard measures, the state government should consider requisitioning these private facilities in order to avoid the spread of the disease due to negligence of private operators.
f) Active involvement of representatives of health workers
The government should engage with trade unions of health workers to ensure that the guidelines effectively reach all concerned health workers. For instance, there is a need for clear information and
training regarding PPE use, disposal, and care. Health worker unions are well positioned to contribute to this process, as they have the organizational ability to reach out to large sections of workers
quickly. Hence, we urge that different state governments involve health worker unions in the process of information-sharing, training, and workers’ safety. Facility management should facilitate an
active role for health workers’ representatives in determining safety measures and safeguards of  their health.

(g) organization of work in hospitals that minimises risk of exposure to healthcare workers
The other part of risk protection is the proper organization of work processes that would limit hospital infection to patients as well as to (all) health workers. This is a part of most quality accredita-
tion programmes, such as the national quality assurance standards for public health facilities and multiple systems for private healthcare facilities. However, only a small proportion of facilities are
registered under these frameworks. One of the reasons why Kerala has reported fewer infections among workers and less spread of the virus overall is because it has much better level of accreditation and infection control. The infection control component of the quality accreditation programmes must be implemented universally across states, including in the private sector, along with a monitoring mechanism by the government.

h) Wages and extra-time to be remunerated as per the law
As society recognises that health workers are contributing to the common good by standing at the frontlines of the battle against the COVID-19 outbreak, longstanding violations of legal provisions with regard to their wages should be acknowledged and addressed. Notifications should be issued so that wages are provided as per existing government norms, and wage discrimination against workers in informal employment should be addressed. The current budgets of most municipal hospitals and state hospitals are too small to provide the legal wages to all workers, which has been covered up through outsourcing of services such as cleaning and housekeeping.
The central government has formalised the central role of ASHAs in containment and community outreach, highlighting once again their role as an essential workforce of the state health system. Yet,
the government guideline does not provide an additional budgetary allocation while, of course, all other tasks are to continue – ante-natal care, vaccination, etc. A paltry Rs 1,000 per month for April and May is to be paid by states from unspent money. Their contribution in the month of March is
not even acknowledged and, without additional budgetary allocation, most State governments might not even pay this inadequate incentive. The government pretence that ASHAs are not workers of the health system amounts to discrimination against an exclusively female workforce that is paid a fraction of the prevalent minimum wage.
Central and State governments should make the required budgetary allocations to ensure that ASHAs and other health workers deployed to respond to the emergency situation are provided the
remuneration they deserve, and at least as per the law. Such allocations should be incorporated in subsequent annual budgets.
As the crisis intensifies, health workers will be asked to provide extra-time on a regular basis. This extra time needs to be regulated to allow enough time-off to rest and recover. Healthcare workers’
burnout aids the spread of the virus. Breaks and time-off need to be maintained. Extra hours should also be remunerated as per the law.
It has also been reported that public and private sector hospitals are forcing their staff to contribute to the government relief fund from their wages, in part of in entirety. Health workers should not be
asked to compulsorily or voluntarily forego their wages in full or partly.
With the exception of specialised doctors, wages in private hospitals and other health facilities in the private sector are abysmally low. This led to the Supreme Court recommending a wage increase across the board in the private health sector (2016). The recommendation has largely been unimplemented. In some states, such as in Delhi, the High Court directed the state government to legislate towards the implementation of the Supreme Court recommendation. Yet, no such steps
have been taken. Considering that health workers in private facilities will also be involved in responding to the COVID-19 epidemic, state governments should ensure compliance with the Supreme Court recommendations relating to wages in private healthcare facilities.
Due to the financial crisis that preceded the COVID-19 pandemic many health workers such as ambulance drivers, but also cleaning staff and ward attendants, had not received their payments for
months. The increased budgetary provision should prioritize payment of such arrears. As the lockdown requires minimising non-essential activities and some workers have been asked to join
duty on alternate days, including for those working in hospital settings, special attention should be given so that those working fewer hours because of the lockdown are paid their full salaries, even if they are hired through manpower agencies, or on short-term contracts and other informal
employment conditions. For instance, safai karamcharis might find it difficult to travel to the hospital they work in because of the shutdown of public transport. They should be considered on
duty for the full period of the lock-down. Finally, private sector hospitals are threatening to cut wages in the month of April due to fewer patients and reduced “business” in that period. The government should actively monitor that wages of health workers are paid. A health worker helpline linked to both the Ministry of Labour and Ministry of Health should be available for health-workers to notify non-payment of wages and arrears.

i) Adequate facilities across needs
Health workers working in high-risk areas, such as isolation wards, have to be provided the option of adequate hostel accommodation so that they can avoid going home where there are old relatives
or young children whose health they are concerned about. They should not be asked to vacate the hostel once their 14-days shift is over, as they risk to expose their families if they go back home.
Separate restrooms for medical personal in direct contact with COVID-19 patients should be provided. Some states have taken steps to provide accommodation to doctors in hotels near the hospitals where their work. There is no justification for the same benefits not being provided to nurses and paramedics in direct contact with patients.
A large proportion of health workers are women who often face the double burden of housework and care for their families as well as work outside the house. Adequate provisions should be made to ease the burden of family care, including by providing options for crèche or childcare outside the
hospital setting. This is essential since regular childcare and schools are shut.
Soap and water should be made available in all facilities for workers and the public as a basic hygiene measure. Hand sanitizers and detergent should be provided to all health workers on a
regular basis to facilitate personal hygiene.
Transport to the place of work, especially for those who do not have private transport, should be provided, particularly if the lockdown is extended. There are reports of cleaning staff in cities such as Delhi not able to join work due to the lockdown and decrease in public transport facilities. This
impacts the smooth functioning of hospitals, as well as creates hardship and stress for the workers who are worried that their salaries will be cut for the days they are not able to attend work. ASHA
workers are facing similar issues as they have to travel from one house to an other.
Lack of nutritious food compromises immunity and puts health workers at risk of coronavirus.
Adequately nutritious food needs to be made available to health workers at the hospital, through the public distribution system, or through other effective systems.

j) Stigma, social exclusion, violence and sexual harassment
We have seen during previous virus outbreaks that health workers are at risk of stigma and social exclusion. Even during the current COVID-19 epidemic there are reports of health workers being
asked to leave their rented accommodation. Other reports have surfaced of health workers being
attacked or harassed during tracing of potential COVID-19 cases or during their routine service delivery. Particularly distressing are reports of healthcare staff who have become victims of COVID-19 being refused burial or cremation services because of such stigma, when it is well known that there is little danger of infection from dead bodies. The government should take appropriate steps to ensure a safe workplace and work environment, including a strong media campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and discrimination. A grievance redressal mechanism should be put in place, including internal complaints committee in case of sexual harassment.
Health workers, including nurses, bringing lapses in treatment and protocols to the attention of the public or speaking out about their working conditions are being gagged and harassed. Hospital management and administrators may be stretched but unethical practices cannot be allowed to
persist and health workers’ role as whistle-blowers should be protected.
Health workers also face violence and harassment from the police while travelling to work, or crossing inter-state barriers to travel from home to their workplace. The government should order health facilities to provide letters on the appropriate official letterhead to all health workers, with an order to the local police and administration to allow their travel, so that they are not harassed
by the police and other officials when travelling to work.

k) Filling of vacancies with a perspective of long-term hiring
Existing gaps in human resources vary between states but are generally substantial. According to information collected through an RTI in 2017, in the facilities under the Delhi government, 14% of the sanctioned posts of general duty medical officers (GDMO) were vacant (though another 4% were filled by contractual staff), and 20% of staff nurse posts were vacant (though the large
majority were actually filled by contractual staff). According to reports, in Uttarakhand, 50% of sanctioned posts for medical officers and 31% for staff nurses are vacant. These vacancies need to be filled urgently, with a perspective of prioritising long-term hiring. The waiting list of the Union Public Services Commission (UPSC) and the Staff Selection Commission (SSC) should be used as a base to fill vacancies in health facilities under the central government. The waiting list of the equivalent board or commission under each state should be used to fill vacancies in facilities under the state governments. Kerala has undertaken this process successfully, using online interviews and video conferencing. More recently, the Government of Tamil Nadu has appointed 530 doctors, 1,000 nurses, and 1,508 lab technicians through this method.
Considering the lockdown and closure of inter-state boarders, the situation might arise where candidates on UPSC) or SSC lists are not in the state where the post is available. In such cases, a temporary adjustment between sanctioned posts under the States and the Centre can be considered.
Considering the need for additional staff, those currently employed on contract should be allowed to continue with their services. However, hiring on a short-term contractual basis or through
manpower agencies should not be seen as an adequate solution for increasing staffing under the impression that the time saved in hiring provides a considerable advantage. Those employed on short-term contracts and contracted through third party agencies are at risk of discrimination with regard to access to personal protective equipment, leave and other safeguards. This increases the
risk of infection of this vulnerable workforce and weakens the risk management process in the facility ― putting the larger public at risk.
The public expenditure on health as a percentage of GDP for 2017-18 was a mere 1.28%, while WHO advises for at least 5% of GDP. Increased budgetary allocation for health will be required to
fill existing vacancies and should be incorporated into subsequent annual budgets.

In summary, our demands are as follows:
SPECIFIC
1. The Government should provide updated guidelines regarding the rational use of PPE that also cover non-COVID-19 facilities, facilitate the production and logistics of distribution,
increase PPE procurement orders to ensure adequate access to all health workers, and if required, intervene in the market to ensure that PPEs are sent to the districts/regions where they are urgently needed.
2. The government should ensure that guidelines regarding the use of PPE are strictly followed in both public and private settings, and that there is no discrimination against workers on the
basis of hierarchy, employment status, or other reasons. A monitoring mechanism should be put in place in order to enforce strict adherence to PPE guidelines in public and private settings.
3. The government should ensure comprehensive health care free of cost to all health workers, including outpatient, hospitalisation, and regular testing, with special attention to informal health workers. Special provision of regular testing needs to be ensured for health workers performing high risk tasks, even if asymptomatic.
4. The government life insurance scheme should cover all health workers including in private settings and the estimate of health workers needs to be modified to reflect the real size of the
health workforce in order to avoid denial of compensation in the future.
5. Special paid leave in case of COVID-19-related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third party. A special
compensation should also be announced for health workers who contract COVID-19 as an occupational disease.
6. Health workers who are pregnant, lactating or have co-morbidities should not be put on duty in the COVID-19 ward. They should be assigned appropriate tasks within their profession that does not expose them to the risk of COVID-19.
7. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected.
8. The government should facilitate appropriate training programmes and materials for the diverse categories of health workers and for the different levels of risk depending on the role
of workers and the role of facilities.
9. Extra hours should be regulated and remunerated as per the law. Breaks and time-off need to be maintained.
10. Adequate arrangements need to be provided to health workers in high-risk environments, such as ICUs and isolation wards, including accommodation and separate restrooms.
11. The government should take appropriate steps to ensure a safe workplace and work environment, protect health workers from harassment by the police and the community, including a strong media campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and discrimination. A grievance redressal mechanism should be put in place,
including internal complaints committee in case of sexual harassment.

INSTITUTIONAL
12. Central and State governments should involve health worker unions in the process of information-sharing, training, and workers’ safety. This will facilitate an effective outreach to all concerned health workers. Managements should facilitate an active role for healthw workers’ representatives in determining safety measures and safeguards of their health.

13. The infection control component of the government’s quality accreditation programmes must be implemented universally across states, including in the private sector, along with a monitoring mechanism by the government. In case private facilities fail to follow the
government guidelines and resolve issues with regard to infection control and other safeguard measures, the state government should consider requisitioning the errant private
facilities.
14. Management of health facilities should make adequate arrangements for health workers at the facility, including but not limited to options for crèche or child care, transport to the place of work, an official letter and an order to the local police and administration so that health workers are not harassed by the police when travelling to work, regular provision of soap and sanitizer, and adequately nutritious food at the hospital or through other effective systems.
15. Health workers who are not able to work on a regular basis due to the lockdown or due to precautionary measures should be considered on duty and paid their full wages. All governments and private facilities should refrain from asking health workers to compulsorily or voluntarily forego their wages in full or partly. A health worker helpline linked to both the Ministry of Labour and Employment and the Ministry of Health and Family Welfare should be available for health workers to notify non-payment of wages and arrears.
16. State governments should ensure compliance with the Supreme Court recommendations relating to the long overdue increase of wages in private healthcare facilities. Relevant directions should be issued in this regard.
17. There should be a health worker helpline that is able to provide online or telephonic support to health workers in both public and private sector, and protect health workers role as whistle-blowers without putting their jobs at risk. This helpline should register complaints and grievances and be linked to competent authorities who would be responsible for taking timely action on these complaints.
18. The waiting list of the UPSC and the SSC should be used as a base to fill vacancies in health facilities under the central government. The waiting list of the equivalent board or commission under each state should be used to fill vacancies in facilities under the state
governments. Health workers hired on a short-term contractual basis are a vulnerable workforce at increased risk of infection. This weakens the risk management process in the facility and puts the larger public at risk.
19. Central and state governments should/must increase their budgetary allocations for health in order to cover health workforce-related costs, such as filling up vacancies, regularization of
informal workers including scheme health workers, payment of wages as per the law and payment of arrears. This increase should be incorporated into subsequent annual budgets.
This will be of long-term benefit for strengthening the public health system in India, and so we can cope better when the next health crisis hits us.